Left Ankle - Achilles Tendinopathy — DVA claim example

Diagnostic Assessment — Left Ankle - Achilles Tendinopathy

Example 1 of 1 · fictitious patient (Veteran E)

Diagnostic Assessment

Left Ankle - Achilles Tendinopathy

BOP Code: 87 of 2024 (Achilles Tendinopathy)
RH Code: 86 of 2024 (Achilles Tendinopathy)

ADF History

Veteran E, date of birth 14 June 1976, Australian Army, Physical Training Instructor, enlisted 20 January 1997, medically discharged 15 March 2022. Operational service: East Timor, 22 September 2000 to 30 March 2001 (warlike); Middle East Area of Operations (Iraq), 10 February 2017 to 30 August 2017 (warlike); Afghanistan, 05 February 2019 to 20 September 2019 (warlike).

Occupational History

As a physical training instructor the veteran led and took part in daily running, pack marching, circuit, plyometric and obstacle-course sessions, often two or three sessions a day, on hard and uneven surfaces and in boots. She also ran remedial and pre-deployment conditioning programs and was required to maintain a high personal fitness standard.

The trade carries a high rate of overuse injury of the lower limbs, including tendinopathy, stress fractures and ankle sprains, and exertional heat illness during training in hot climates. Deployed instructors worked long days with limited access to physiotherapy, podiatry and specialist care.

History

Veteran E, a physical training instructor in the Australian Army, developed left mid-portion Achilles tendinopathy on 10 June 2017 while deployed to Iraq, after a sharp increase in her running and training load on a background of renal transplantation, long-term prednisolone, letrozole, diabetes, obesity, spondyloarthropathy and a stiff, unstable left foot and ankle. The tendinopathy worsened to a complete rupture of the left Achilles tendon on 02 September 2019 while she was deployed to Afghanistan, after a glucocorticoid injection and seven months without appropriate treatment.

Timeline

• 14 Nov 2000 — During warlike service in East Timor the veteran was admitted to the role 2 facility with bloody diarrhoea; stool culture grew Shigella flexneri. Three weeks later she developed reactive arthritis of both knees and the left ankle, with conjunctivitis, and was found to be HLA-B27 positive. In the same month she sustained a severe inversion injury of the left ankle on a patrol, and recurrent giving way followed. "Shigella dysentery, reactive arthritis, HLA-B27"
• 12 Feb 2008 — The veteran collapsed with exertional heat stroke while leading a pack march on a field exercise in northern Australia. Core temperature was 41.6 degrees with rhabdomyolysis and acute kidney injury. Renal function did not recover (bilateral cortical necrosis on biopsy) and she began chronic haemodialysis on 20 February 2008, with an eGFR below 15 mL/min/1.73 m2 from then until transplantation. "heat stroke, AKI, haemodialysis commenced"
• 18 Nov 2010 — A renal transplant surgeon performed a living donor kidney transplant. Immunosuppression was tacrolimus, mycophenolate and prednisolone 20 mg daily, reduced to a maintenance dose of 10 mg daily from March 2011 and continued throughout the rest of her service. She returned to full instructional duties in 2011. "renal transplant, prednisolone 10 mg maintenance"
• 09 Mar 2016 — A rheumatologist summarised her inflammatory arthritis: ankylosing spondylitis evolving from reactive arthritis, enteropathic spondyloarthropathy with Crohn disease, psoriatic arthropathy, seropositive rheumatoid arthritis, Behcet syndrome with oral and genital ulceration, tacrolimus-related gout and calcium pyrophosphate arthropathy. New-onset diabetes after transplantation had been diagnosed in 2012 (HbA1c 7.9 per cent). An oncologist had commenced letrozole 2.5 mg daily on 01 Feb 2016 after surgery for oestrogen receptor positive left breast cancer. BMI 31.2. "multiple spondyloarthropathies, gout, CPPD"
• 12 Jun 2017 — While deployed to Iraq as the training team's instructor, she presented to the role 1 facility with two days of left posterior heel pain and morning stiffness, worse at the start of runs. She had doubled her daily training load the week before. Examination showed a tender fusiform swelling of the left Achilles tendon 4 cm above the insertion, a pes cavus foot with forefoot varus, ankle dorsiflexion of 5 degrees and a positive anterior drawer. She had completed ciprofloxacin for transplant pyelonephritis on 27 May 2017. "tender L Achilles mid-portion, swelling"
• 25 Sep 2017 — After return to Australia, MRI confirmed left mid-portion Achilles tendinopathy with intrasubstance degeneration. A sports physician confirmed the diagnosis and commenced an eccentric loading program, heel raises and podiatry orthoses. Symptoms improved partially but did not resolve. In April 2018 a left tibialis posterior tendon rupture led to progressive collapse of the arch. "MRI confirms mid-portion tendinopathy"
• 03 Jan 2019 — With persisting posterior heel pain before her second deployment, a sports physician injected 40 mg of triamcinolone into the left retrocalcaneal bursa and the region of the Achilles tendon under ultrasound guidance. The podiatrist now recorded an acquired flat foot on the left after the tibialis posterior rupture. A course of oral prednisolone 50 mg daily for 10 days had been given for a Crohn disease flare in December 2018. "retrocalcaneal bursa injection, triamcinolone 40 mg"
• 02 Sep 2019 — On warlike service in Afghanistan, with no physiotherapy or follow-up imaging available for the previous seven months, she felt a sudden snap in the left heel while sprinting in a fitness assessment. Thompson test positive with a palpable gap. Ultrasound on 04 Sep 2019 showed a complete rupture of the degenerate tendon 4 cm above the insertion. She had taken ciprofloxacin for dysentery from 14 to 20 Aug 2019. "complete L Achilles rupture, Thompson positive"
• 25 Sep 2019 — After aeromedical return, an orthopaedic surgeon performed an open repair of the left Achilles tendon, noting extensive degeneration of the tendon ends. Recovery was slow and complicated by wound breakdown, and she was medically discharged on 15 Mar 2022 with persisting weakness and pain. "open repair, degenerate tendon ends"

Symptoms

At onset the veteran had pain and morning stiffness in the left posterior heel, worse at the start of running and after rest, with a tender swelling of the tendon. After onset the pain became constant with prolonged walking and limited her running, and in September 2019 she sustained a complete rupture.

She now reports left calf weakness, inability to run or jump, heel pain after walking more than one kilometre and stiffness each morning. She cannot perform a single-leg heel raise on the left.

Imaging

• 22 Jun 2017 — Ultrasound left Achilles tendon (role 2 facility, Iraq): "Fusiform thickening of the mid-portion of the tendon to 9 mm, 4 cm above the insertion, with hypoechoic change and neovascularity. No tear."
• 25 Sep 2017 — MRI left ankle: "Mid-portion Achilles tendinopathy with intrasubstance degeneration and paratenon oedema. Mild retrocalcaneal bursitis."
• 04 Sep 2019 — Ultrasound left Achilles tendon: "Complete full-thickness rupture of a degenerate tendon 4 cm above the calcaneal insertion with a 2.5 cm gap in plantar flexion."

Onset Date

The most likely date of onset of this condition is 10 Jun 2017.

At that date the veteran was on warlike service in Iraq, instructing a coalition training team. In the week before, her daily training load had doubled, and she was taking prednisolone, tacrolimus and letrozole and had recently completed ciprofloxacin.

This date is appropriate because her pre-deployment medical examination of 15 Jan 2017 recorded no heel or calf symptoms, and she first presented on 12 Jun 2017 with pain of two days' duration. It falls within continuous full-time service.

For the running factors, the 4 weeks before onset run from 13 May 2017 to 10 Jun 2017; she ran about 65 kilometres a week in that period. For the weight bearing exercise factor, the same 4 weeks were filled by about 10 hours a week of instructional sessions. For the increase in activity, the 1 week before onset runs from 03 Jun 2017 to 10 Jun 2017. For the fluoroquinolone factor, the 30 days before onset run from 11 May 2017 to 10 Jun 2017, and she took ciprofloxacin from 20 to 27 May 2017. For the aromatase inhibitor factor, the 1 year before onset runs from 10 Jun 2016 to 10 Jun 2017, during which she took letrozole daily. For the chronic renal failure factor, the 10 years before onset run from 10 Jun 2007 to 10 Jun 2017, and she was on dialysis from February 2008 to November 2010. Prednisolone was taken continuously from 18 Nov 2010, and the foot and ankle conditions, the arthritic diseases, diabetes and a BMI over 30 were each present on 10 Jun 2017.

For the worsening factors, the documented clinical worsening is the complete rupture on 02 Sep 2019. The 4 weeks before it run from 05 Aug 2019 to 02 Sep 2019, the 1 week before it from 26 Aug 2019 to 02 Sep 2019, and the 30 days before it from 03 Aug 2019 to 02 Sep 2019. The 1 year before it runs from 02 Sep 2018 to 02 Sep 2019, and the 10 years before it from 02 Sep 2009 to 02 Sep 2019, which include fourteen months of dialysis. The glucocorticoid injection of 03 Jan 2019 preceded the rupture.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Left Achilles Tendinopathy, mid-portion (ICD-10 M76.6), complicated by complete rupture of the left Achilles tendon, under the Statements of Principles concerning Achilles tendinopathy, Balance of Probabilities No. 87 of 2024 and Reasonable Hypothesis No. 86 of 2024.

Achilles tendinopathy is a symptomatic inflammatory or degenerative disease of the Achilles tendon or paratendon. Repetitive loading beyond the tendon's capacity to adapt causes disorganised collagen, increased ground substance and new vessel growth, producing pain, stiffness and swelling, usually 2 to 7 cm above the insertion. A degenerate tendon is weaker and prone to partial and complete tears, and a rupture of a tendinopathic tendon is a clinical worsening of the condition.

The condition followed a sudden escalation of running and training load on deployment, on a background of long-term glucocorticoid treatment after renal transplantation, letrozole, diabetes, obesity, multiple spondyloarthropathies and a stiff, malaligned and unstable left foot and ankle. It began on 10 June 2017, was confirmed on ultrasound and MRI in 2017 and worsened to a complete rupture on 02 September 2019.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

10 June 2017.

When did the veteran first present to a health / medical provider for this condition?

12 June 2017.

When was the condition confirmed / formally diagnosed?

22 June 2017.

When did the veteran first present to you (or your practice) for this condition?

18 June 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by ultrasound on 22 June 2017, which showed fusiform thickening of the mid-portion of the left Achilles tendon to 9 mm with hypoechoic change and neovascularity, and by MRI on 25 September 2017, which showed intrasubstance degeneration and paratenon oedema. This meets the Statement of Principles definition of Achilles tendinopathy, which includes mid-portion tendinopathy and degenerative tears.

The clinical picture was consistent: posterior heel pain and morning stiffness, a tender fusiform swelling 4 cm above the insertion and pain on hopping. A sports physician confirmed the diagnosis on 25 September 2017. The complete rupture on 02 September 2019 was confirmed by a positive Thompson test, ultrasound and the operative findings of degenerate tendon ends on 25 September 2019.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

Legislation: the clinical onset of this condition was on 10 June 2017, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2017, where the condition began, in Afghanistan in 2019, where it worsened to a rupture, and in East Timor in 2000 to 2001, where the reactive arthritis and ankle instability arose.

In these instruments each factor applies to either the clinical onset or the clinical worsening of the condition, and the final factor applies to worsening only. Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Achilles Tendinopathy, No. 87 of 2024

Causative factors (clinical onset or clinical worsening)

Factor 9(1): running or jogging an average of at least 60 kilometres per week for the 4 weeks before clinical onset or clinical worsening; — MET

- The veteran ran an average of about 65 kilometres a week in the 4 weeks before onset, from 13 May 2017 to 10 June 2017, as a deployed physical training instructor in Iraq, combining trainee runs with her own conditioning for a unit fitness competition. In the 4 weeks before the rupture, from 05 August 2019 to 02 September 2019, she again ran about 62 kilometres a week on deployment in Afghanistan.

Factor 9(2): undertaking weight bearing exercise involving repeated activity of the ankle joint on the affected side for: (a) a minimum intensity of 5 METS; and (b) for at least 6 hours per week; and (c) for at least the 4 weeks before clinical onset or clinical worsening; — MET

- In the 4 weeks before onset she undertook about 10 hours a week of weight bearing exercise involving repeated left ankle activity at well over 5 METs, including pack marching, plyometric drills, shuttle runs and obstacle-course instruction. The same load, about 9 hours a week, filled the 4 weeks before the rupture.

Factor 9(3): increasing the frequency, duration or intensity of activity involving the ankle joint on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 4 hours per day; within the 1 week before the clinical onset or clinical worsening; — MET

- From 03 June 2017, when a second training course began, her daily activity rose from about 2 hours to about 4.5 hours of running, marching and jumping drills, an increase of more than 100 percent at well over 5 METs, within the 1 week before onset on 10 June 2017. From 26 August 2019 she ran two daily fitness assessment preparation sessions, rising from 2 to 4 hours a day within the 1 week before the rupture.

Factor 9(4)(a): having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: decreased ankle or forefoot flexibility; — MET

- Ankle dorsiflexion on the left was limited to 5 degrees, with a weight-bearing lunge distance of 6 cm against 12 cm on the right, after the left ankle injury in East Timor in 2000. This decreased ankle flexibility was recorded at presentation on 12 June 2017 and persisted at the rupture in 2019.

Factor 9(4)(b): having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: forefoot varus; — MET

- A podiatrist measured a left forefoot varus of 8 degrees in 2014, recorded again at presentation on 12 June 2017 and present at the rupture in 2019.

Factor 9(5)(a): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: ankylosing spondylitis; — MET

- Ankylosing spondylitis, evolving from the reactive arthritis that followed Shigella dysentery on warlike service in East Timor in 2000, was confirmed by bilateral sacroiliitis on MRI in 2008 and was active at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(5)(b): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: Behcet syndrome; — MET

- A rheumatologist diagnosed Behcet syndrome in 2014 on recurrent oral and genital ulceration with anterior uveitis and a positive pathergy test. It was present at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(5)(c): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: enteropathic spondyloarthropathy (arthritis associated with inflammatory bowel disease); — MET

- Crohn disease was diagnosed on colonoscopy in 2011, with an associated enteropathic spondyloarthropathy affecting the ankles and spine. It was present at onset on 10 June 2017 and at the rupture on 02 September 2019, with a flare treated in December 2018.

Factor 9(5)(d): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: gout; — MET

- Tophaceous gout, caused by tacrolimus after her 2010 renal transplant, was confirmed by urate crystals on aspiration of the left first metatarsophalangeal joint in 2012. It was present at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(5)(e): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: pseudogout (calcium pyrophosphate dihydrate) or crystal-induced arthropathy from the deposition of calcium hydroxyapatite or calcium oxalate; — MET

- Calcium pyrophosphate dihydrate arthropathy, linked to tacrolimus-induced hypomagnesaemia, was confirmed by crystal analysis of a knee aspirate in 2013, with chondrocalcinosis on X-ray. It was present at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(5)(f): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: psoriatic arthropathy; — MET

- Psoriasis with psoriatic arthropathy of the hands and feet, including dactylitis of the left second toe, was diagnosed in 2013 and was present at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(5)(g): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: reactive arthritis; — MET

- Reactive arthritis followed culture-confirmed Shigella dysentery on warlike service in East Timor in November 2000, with recurrent flares in the left ankle and heel, and was present at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(5)(h): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: rheumatoid arthritis; — MET

- Seropositive rheumatoid arthritis, with positive rheumatoid factor and anti-CCP antibodies and erosions of the hands, was diagnosed in 2015 and was present at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(5)(i): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: undifferentiated spondyloarthropathy; — MET

- A rheumatologist recorded undifferentiated spondyloarthropathy with heel enthesitis in 2003, before the later diagnoses were made, and it remained documented at onset on 10 June 2017 and at the rupture on 02 September 2019.

Factor 9(6): being treated with a fluoroquinolone antibiotic within the 30 days before clinical onset or clinical worsening; — MET

- The veteran was treated with a fluoroquinolone, ciprofloxacin 500 mg twice daily, from 20 to 27 May 2017 for pyelonephritis of her transplanted kidney, within the 30 days before onset on 10 June 2017. She took ciprofloxacin again from 14 to 20 August 2019 for dysentery in Afghanistan, within the 30 days before the rupture.

Factor 9(7): being treated with a glucocorticoid drug as specified before clinical onset or clinical worsening; — MET

- The veteran took prednisolone continuously from 18 November 2010 after her renal transplant, 20 mg daily to March 2011 and 10 mg daily thereafter, a cumulative oral dose of more than 23 grams by onset. This exceeds the specified 10 grams and also the 0.5 grams over 6 months within the 3 years before onset and before the rupture.

Factor 9(8): having a glucocorticoid injection into the Achilles tendon, in the region of the Achilles tendon or in the retrocalcaneal bursa, before the rupture of the Achilles tendon; — MET

- On 03 January 2019 a sports physician injected 40 mg of triamcinolone into the left retrocalcaneal bursa and the region of the Achilles tendon under ultrasound guidance. The complete rupture of the tendon followed on 02 September 2019.

Factor 9(9): being treated with an aromatase inhibitor for at least 4 weeks within the 1 year before clinical onset or clinical worsening; — MET

- The veteran took the aromatase inhibitor letrozole 2.5 mg daily from 01 February 2016 for breast cancer, throughout the 1 year before onset, from 10 June 2016 to 10 June 2017, and throughout the 1 year before the rupture.

Factor 9(10): having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening; — MET

- The veteran's BMI was 31.2 in March 2016 and 31.4 at presentation on 12 June 2017, the weight gain attributed to long-term prednisolone. Her BMI was 32.0 at the rupture in September 2019.

Factor 9(11): having diabetes mellitus at the time of clinical onset or clinical worsening; — MET

- New-onset diabetes mellitus after transplantation was diagnosed in 2012, with an HbA1c of 7.9 per cent, caused by tacrolimus and prednisolone. It was present at onset on 10 June 2017 and at the rupture on 02 September 2019, treated with metformin and gliclazide.

Worsening factors

Factor 9(12): inability to obtain appropriate clinical management for Achilles tendinopathy before clinical worsening. — MET

- From February to September 2019, on warlike service in Afghanistan, the veteran had no access to physiotherapy, podiatry or follow-up imaging for her diagnosed tendinopathy, and her planned specialist review was deferred until her return. She continued full instructional duties and fitness testing without a modified program, and the degenerate tendon ruptured on 02 September 2019. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.

Reasonable Hypothesis — Statement of Principles concerning Achilles Tendinopathy, No. 86 of 2024

Causative factors (clinical onset or clinical worsening)

Factor 9(1): running or jogging an average of at least 30 kilometres per week for the 4 weeks before clinical onset or clinical worsening; — MET

- In the 4 weeks before onset, from 13 May 2017 to 10 June 2017, the veteran ran about 65 kilometres a week while on warlike service in Iraq, and in the 4 weeks before the rupture she ran about 62 kilometres a week on warlike service in Afghanistan, both well above 30 kilometres.

Factor 9(2): undertaking weight bearing exercise involving repeated activity of the ankle joint on the affected side for: (a) a minimum intensity of 5 METS; and (b) for at least 4 hours per week; and (c) for at least the 4 weeks before clinical onset or clinical worsening; — MET

- On warlike service in Iraq she undertook about 10 hours a week of pack marching, plyometric and obstacle-course instruction at well over 5 METs in the 4 weeks before onset, and about 9 hours a week in Afghanistan in the 4 weeks before the rupture.

Factor 9(3): increasing the frequency, duration or intensity of activity involving the ankle joint on the affected side: (a) by at least 100 percent; and (b) to a minimum intensity of 5 METs; and (c) for at least 2 hours per day; within the 1 week before the clinical onset or clinical worsening; — MET

- On warlike service in Iraq her daily activity rose from about 2 to 4.5 hours of running, marching and jumping drills from 03 June 2017, within the 1 week before onset. In Afghanistan it rose from 2 to 4 hours a day from 26 August 2019, within the 1 week before the rupture.

Factor 9(4)(a): having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: pes planus; — MET

- Before April 2018 the left foot had a high-arched cavus shape, but after the left tibialis posterior tendon rupture of April 2018 the arch collapsed. A podiatrist recorded an acquired left flat foot on 03 January 2019, and pes planus was present at the rupture on warlike service in Afghanistan on 02 September 2019.

Factor 9(4)(b): having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: pes cavus; — MET

- A left pes cavus foot with a calcaneal pitch of 32 degrees was recorded at enlistment and by a podiatrist in 2014, and was present at onset on warlike service in Iraq on 10 June 2017.

Factor 9(4)(c): having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: decreased ankle or forefoot flexibility; — MET

- Left ankle dorsiflexion was limited to 5 degrees after the inversion injury on warlike service in East Timor in 2000, and was present at onset in Iraq and at the rupture in Afghanistan.

Factor 9(4)(d): having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: forefoot varus; — MET

- A left forefoot varus of 8 degrees was recorded in 2014 and at presentation in Iraq on 12 June 2017, and was present at the rupture.

Factor 9(4)(e): having one or more of the following conditions involving the affected lower limb at the time of clinical onset or clinical worsening: lateral ankle joint instability; — MET

- A severe inversion injury of the left ankle on patrol on warlike service in East Timor in November 2000 led to recurrent giving way, with a positive anterior drawer test recorded at presentation on 12 June 2017. Lateral ankle instability was present at onset and at the rupture.

Factor 9(5)(a): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: ankylosing spondylitis; — MET

- Ankylosing spondylitis evolved from the reactive arthritis that followed Shigella dysentery on warlike service in East Timor in 2000, and was active at onset in Iraq and at the rupture in Afghanistan.

Factor 9(5)(b): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: Behcet syndrome; — MET

- Behcet syndrome, diagnosed in 2014, was present at onset on warlike service in Iraq and at the rupture on warlike service in Afghanistan.

Factor 9(5)(c): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: enteropathic spondyloarthropathy (arthritis associated with inflammatory bowel disease); — MET

- Enteropathic spondyloarthropathy with Crohn disease, diagnosed in 2011, was present at onset in Iraq and at the rupture in Afghanistan.

Factor 9(5)(d): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: gout; — MET

- Gout caused by tacrolimus after her renal transplant was present at onset in Iraq and at the rupture in Afghanistan. The transplant followed renal failure from exertional heat stroke in service in 2008.

Factor 9(5)(e): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: pseudogout (calcium pyrophosphate dihydrate) or crystal-induced arthropathy from the deposition of calcium hydroxyapatite or calcium oxalate; — MET

- Calcium pyrophosphate arthropathy, linked to tacrolimus-induced hypomagnesaemia, was present at onset in Iraq and at the rupture in Afghanistan.

Factor 9(5)(f): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: psoriatic arthropathy; — MET

- Psoriatic arthropathy, diagnosed in 2013, was present at onset in Iraq and at the rupture in Afghanistan.

Factor 9(5)(g): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: reactive arthritis; — MET

- Reactive arthritis followed Shigella dysentery contracted on warlike service in East Timor in November 2000 and was present at onset in Iraq and at the rupture in Afghanistan.

Factor 9(5)(h): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: rheumatoid arthritis; — MET

- Seropositive rheumatoid arthritis, diagnosed in 2015, was present at onset in Iraq and at the rupture in Afghanistan.

Factor 9(5)(i): having one of the following systemic arthritic diseases at the time of clinical onset or clinical worsening: undifferentiated spondyloarthropathy; — MET

- Undifferentiated spondyloarthropathy with heel enthesitis, first recorded in 2003 after the East Timor reactive arthritis, was present at onset and at the rupture.

Factor 9(6): having chronic renal failure within the 10 years before clinical onset or clinical worsening as indicated by: (a) a glomerular filtration rate of less than 15 mL/min/1.73 m2 for a period of at least 3 months; or (b) undergoing chronic dialysis for renal failure; — MET

- Exertional heat stroke on a field exercise in February 2008 caused renal failure, and the veteran underwent chronic haemodialysis from 20 February 2008 to 18 November 2010, with an eGFR below 15 mL/min/1.73 m2 for more than 3 months. This falls within the 10 years before onset in Iraq and within the 10 years before the rupture in Afghanistan.

Factor 9(7): being treated with a fluoroquinolone antibiotic within the 30 days before clinical onset or clinical worsening; — MET

- Ciprofloxacin was given from 20 to 27 May 2017 on warlike service in Iraq, within the 30 days before onset, and from 14 to 20 August 2019 on warlike service in Afghanistan, within the 30 days before the rupture.

Factor 9(8): being treated with a glucocorticoid drug as specified before clinical onset or clinical worsening; — MET

- Prednisolone was taken continuously from November 2010, a cumulative dose of more than 23 grams before onset in Iraq, plus a 10-day course of 50 mg daily in December 2018 before the rupture in Afghanistan.

Factor 9(9): having a glucocorticoid injection into the Achilles tendon, in the region of the Achilles tendon or in the retrocalcaneal bursa, before the rupture of the Achilles tendon; — MET

- The triamcinolone injection into the left retrocalcaneal bursa and region of the Achilles tendon on 03 January 2019 preceded the rupture on warlike service in Afghanistan on 02 September 2019.

Factor 9(10): being treated with an aromatase inhibitor for at least 4 weeks within the 1 year before clinical onset or clinical worsening; — MET

- Letrozole was taken daily from 01 February 2016, for more than 4 weeks within the 1 year before onset in Iraq and within the 1 year before the rupture in Afghanistan.

Factor 9(11): having a Body Mass Index (BMI) of 30 or greater at the time of clinical onset or clinical worsening; — MET

- The veteran's BMI was 31.4 at presentation on warlike service in Iraq on 12 June 2017 and 32.0 at the rupture in Afghanistan.

Factor 9(12): having diabetes mellitus at the time of clinical onset or clinical worsening; — MET

- Diabetes mellitus after transplantation, diagnosed in 2012, was present at onset in Iraq and at the rupture in Afghanistan.

Worsening factors

Factor 9(13): inability to obtain appropriate clinical management for Achilles tendinopathy before clinical worsening. — MET

- On warlike service in Afghanistan from February to September 2019 the veteran could not obtain physiotherapy, podiatry, imaging or specialist review for her diagnosed tendinopathy, and she continued full duties until the tendon ruptured on 02 September 2019.

The % contribution of the causes is 100% and significant.

Sequelae

The left Achilles tendinopathy is a sequela of the veteran's accepted conditions: the left ankle instability and stiffness from the 2000 inversion injury, the reactive arthritis and spondyloarthropathy that followed dysentery in East Timor, and the long-term prednisolone that followed renal failure from exertional heat stroke in service.

Unintended Consequence

Met. The tendinopathy and the rupture are in part an unintended consequence of treatment provided while the veteran was serving: ciprofloxacin, long-term prednisolone after her renal transplant and the triamcinolone injection of 03 January 2019 are each recognised causes of tendon degeneration and rupture (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. From February to September 2019, on warlike service in Afghanistan, the veteran had no access to physiotherapy, podiatry, imaging or specialist review for her diagnosed tendinopathy, and she continued full instructional duties and fitness testing without modification until the degenerate tendon ruptured on 02 September 2019. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent appropriate treatment and activity modification amount to an inability to obtain appropriate clinical management. The progression from tendinopathy to complete rupture is the clinical worsening that followed.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 14 Nov 2000, Inpatient record and stool culture, Role 2 facility, East Timor
2. 12 Feb 2008, Emergency and intensive care admission, Regional hospital
3. 18 Nov 2010, Operation report, Renal transplant surgeon
4. 01 Feb 2016, Oncology consultation, Medical oncologist
5. 09 Mar 2016, Specialist letter, Rheumatologist
6. 15 Jan 2017, Pre-deployment medical examination, Medical Officer
7. 12 Jun 2017, Outpatient health record, Medical Officer, Role 1 facility, Iraq
8. 22 Jun 2017, Ultrasound left Achilles tendon, Role 2 facility, Iraq
9. 25 Sep 2017, MRI left ankle and consultation, Sports physician
10. 03 Jan 2019, Procedure note, Sports physician
11. 02 Sep 2019, Outpatient health record, Medical Officer, Afghanistan
12. 04 Sep 2019, Ultrasound left Achilles tendon, Radiologist
13. 25 Sep 2019, Operation report, Orthopaedic surgeon
14. Statement of Principles concerning Achilles Tendinopathy (Balance of Probabilities) No. 87 of 2024, Repatriation Medical Authority
15. Statement of Principles concerning Achilles Tendinopathy (Reasonable Hypothesis) No. 86 of 2024, Repatriation Medical Authority